Original Article

Pattern of Ocular Problems in School going

Children of District Lasbela, Balochistan
Khalil A. Lakho, M. Zahid Jadoon, P.S. Mahar

Pak J Ophthalmol 2012, Vol. 28 No. 4

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See end of article for Purpose: To find out the pattern of eye problems in children of age 6 to 15
authors affiliations years, attending schools and madaris (religious schools) and also to determine
the difference in prevalence of ocular disease in students attending these
…..……………………….. different types of institutions.
Correspondence to: Material and Methods: The study was conducted in Madaris of district Lasbela
Khalil A. Lakho were screened from February 2008 to September 2009. All students of schools /
Community Ophthalmologist madaris of district Lasbela were included in the study. The visual acuity (VA) was
Isra Postgraduate Institute of
measured using standard Snellen’s chart; external examination was carried out
Ophthalmology
Al-Ibrahim Eye Hospital
with the help of magnifying loop and direct ophthalmoscope. The children with
Karachi VA < 6/12 were refracted to the best correction. The study team included a
community ophthalmologist, an ophthalmologist, an ophthalmic technician and a
community social worker. A structured questionnaire was prepared and
operational methods were field tested and refined by piloting at the outpatient of
Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital (AIEH),
Karachi. An ophthalmic technician with community social worker checked vision
of all the students and an Ophthalmologist examined the children for any
abnormality and referred them to the base hospital (AIEH). All children with VA
< 6/12 were refracted. Every school and madarsa of the target area was visited.
Results: Out of 25,437 examined school going children, 19,629 (77.16%) were
found to be normal while 5,808 (22.84%) had ocular problems. The ocular
conditions in order of frequency were conjunctivitis in 2,826 (11.10%) children,
vitamin A deficiency disorders in 839 (3.29%) children, refractive error in 740
(2.90%) children, vernal conjunctivitis in 484 (1.90%) children, blepheritis in 373
(1.46%) children, strabismus in 119 (0.46%) children, cataract in 45 (0.17%)
children, ptosis in 33 (0.12) children, nystagmus in 26 (0.10%) children,
glaucoma in 2 (0.007%) children and non-specific ocular changes were found in
259 (1.01%) children. The prevalence of ocular problems occurred in 20.68% of
children in main stream schools compared to 34.33% in children studying in
madaris. The main difference in prevalence was of conjunctivitis noticed in
10.03% of school children, compared to 17% of madaris students and of
refractive error present in 2.14% of school children, compared to 7% of students
in madaris.
Conclusion: Almost 23% of school going children in Lasbela district needed
treatment for their ocular problems. The prevalence of conjunctivitis and
refractive error was more in madaris compared to schools. School screening
could play an important role in the promotion of eye health and the prevention of
…..……………………….. childhood blindness.

200 Vol. 28, No. 4, Oct – Dec, 2012 Pakistan Journal of Ophthalmology
 PATTERN OF OCULAR PROBLEMS IN SCHOOL GOING CHILDREN OF DISTRICT LASBELA, BALOCHISTAN
O
cular problems, mainly leading to visual
disability are important not because of the
gross number but because of the number of
blind years and its impact on the socio-economic
condition of the community and country. The
childhood blindness affects the entire family and
many of them are left as street beggars in the poor
countries. This has drawn the attention of World
Health Organization’s Vision 2020 program, which has
included “Childhood Blindness” as one of its targets.
There are an estimated 1.4 million blind children
in the world1. One million of them reside in Asia.
Every year, approximately half a million children add
to this total (about one blind child every minute). The
common causes of blindness in children are vitamin A
deficiency disorders (VADD), refractive error,
trachoma and hereditary / congenital diseases.
Baluchistan, the largest province of Pakistan, is in
the southeastern region of the country. It is moun-
tainous and dry, with population of about 6.5 million
people2. It is an under privileged province with poor
health care, especially the eye care delivery. There are
not many optical shops in most districts of Baluchistan
and services for refraction are almost non-existing. The
school going children have to suffer from this lack of
eye care and this may be one of the important
constrains towards achieving good literacy rate.
There are no reliable data available on the
problems of school going children in Pakistan except a
study by Afghani3 showing 4.24% of school going
children having refractive error. There is a remarkable
difference between mainstream schools and religious
schools regarding socio-economic status, learning
environment and “reading hours”. In religious schools
students are expected to have long recitation hours
(about 10 hours a day) in contrast to schools (1-2 hours
a day). This difference may have some effect on the
growth of the eye resulting in the higher prevalence of
refractive error.4-6 The purpose of our study was to
determine the pattern of eye problems in government
sponsored schools and madaris and to find out the
difference of prevalence of eye conditions existent in
these two different settings.
MATERIAL AND METHODS
All student age 6-15 years studying in government
sponsored schools and madaris in Lasbela district of
Balochistan were screened for the presence of any
ocular problem from February 2008 to September
2009.
Pakistan Journal of Ophthalmology
A team consisting of community ophthalmologist
clinical ophthalmologist, ophthalmic technician and
community social worker was formed and briefed
about the structured questionnaire to collect the data
and different aspects of the study. The team visited all
the schools and madaris according to the schedule.
The children examined belonged to the rural and
urban areas, studying in primary, middle and high
schools and madaris for girls and boys from the entire
district Labella. About 100 students were examined
per day. A total number of 25,437 school going
children were examined. The visual acuity of each
child was assessed using snellen’s chart; the external
ocular examination was carried out with magnifying
loop and fundus was examined with direct
ophthalmoscope after dilatation. A cyclyplegic
refraction was carried out in children with VA < 6/12.
All children requiring glasses were provided
spectacles and treatment was given for common
ocular conditions like conjunctivitis and vernal
conjunctivitisetc. The children with Xerophthalmia
were provided vitamin A capsules and health
education reading material. The children needing
surgical intervention were referred to the tertiary eye
care center at Isra Postgraduate Institute of
Ophthalmology, Al-Ibrahim Eye Hospital, Karachi.
The permission for this study was sought from the
education department of Lasbela district and the
school headmasters/heads of madaris were requested
to allow the screening. Efforts were made to educate at
least one teacher in each school / Madrasa who could
in the future check vision of the children. Snellen’s
charts were provided to each school without cost. The
screening was conducted in the teaching institutions
mainstream or religious, of the district Lasbela
consisting of Hub, Winder, Dureji, Uthal, Liari, Lakhra
and Belatahseels.
The data analysis was conducted with the
statistical package for social sciences (SPSS) version
(14.0) the values were presented in the form of
frequencies and percentages and the proportion test
was used to observe the significance. The difference
between two groups (children of schools and madaris)
was analyzed through Z-proportion test and p-value
of < 0.05 was considered statistically significant.
RESULTS
We examined 21,432 school going children (6-15 years)
in government sponsored schools and 4,005 students
attending various madaris (total 25,437) with 2,487
students found absent.
Vol. 28, No. 4, Oct – Dec, 2012 201
KHALIL A. LAKHO, et al
Out of 4,005 students of religious schools, 1,375
(34.33%) and out of 21,432 students of state run
schools, 4,433 (20.68%) had ocular problems. The
ocular conditions in order of frequency were
conjunctivitis in 2,826 (11.10%) children, vitamin A
deficiency disorder (bitot’s spots and Xerophthalmia)
in 839 (3.29%) children, refractive error in 740 (2.90%)
children, vernal conjunctivitis in 484 (1.90%) children,
blepheritis in 373 (1.46%) children, strabismus in 119
(0.46%) children, cataract in 45 (0.17%) children, ptosis
in 33 (0.12) children, nystagmus in 26 (0.10%) children,
glaucoma in 2 (0.007%) children and non-specific
ocular features were seen in 259 (1.01%) children. The
non-specific ocular changes included mild
conjunctival redness and watering for which no
specific reason was found. There was a considerable
difference in the prevalence of eye problems between
two institutions. The prevalence of ocular problems
occurred in 20.68% of children in mainstream schools
compared to 34.33% in children studying in madaris.
The detailed examination (Table 1) showed that
conjunctivitis, refractive error and vernal
conjunctivitis were responsible for the main difference.
The common eye ailment found was conjunctivitis
(11.12%), more common in religious schools (17.07%)
than in government schools (10.03%). Refractive error
was found in 2.9% children. When considered
separately, 2.14% children in government schools were
found to be in need for correction with glasses,
whereas 17.0% children in religious schools needed
refractive correction. The overall prevalence of vernal
conjunctivitis was 1.90%, with 1.62% children having it
in schools compared to 3.33% pupils in madaris. The
pattern of other eye disease was almost same in the
two institutions. The p-value of all ocular problems in
schools and madaris is mentioned in Table 1. The
number of children referred to the base hospital was
261 (4.49%) from schools and 48 (3.4%) from madaris.
DISCUSSION
The prevention and control of blindness in children is
considered a high priority by World Health Organi-
zation’s Vision 2020; the Right to Sight Program.
There are 1.4 million blind children in the world
and approximately 500,000 children become blind
every year i.e. one every minute – and about half of
them die within one or two years of becoming blind.
The children who are born blind or who become blind
and survive have a lifetime of blindness ahead of
them, with all the associated emotional, social and
economic costs to the child, the family, and the
202 Vol. 28, No. 4, Oct – Dec, 2012
society8. Indeed, the number of ‘‘blind years’’ due to
all causes of blindness in children is almost equal to
the number of ‘‘blind years’’ due to cataract in adults,
which is around 70 million years.9 Unfortunately all
these children remain uneducated and unskilled. In
terms of economic loss, approximately one third of the
total economic cost of blindness is thought to be due to
childhood blindness. The control of childhood
blindness is therefore also linked to the education and
the poverty.
Many of the causes of blindness in children are
either preventable or treatable. The conditions
associated with the blindness in children are also
causes of child mortality such as premature birth,
measles, congenital rubella syndrome, vitamin A
deficiency and meningitis. The control of blindness in
children is therefore, closely linked to the child
survival. Reducing visual loss in children poses
particular challenges, which are different from the
challenges of controlling adult blindness. The children
are born with an immature visual system and for
normal visual development to occur, they need clear,
focused images to be transmitted to the higher visual
center. The failure of normal visual maturation
(Amblyopia) cannot be corrected in the adult life, so
there is a level of urgency about treating childhood
eye disease.
The major causes of blindness in children vary
widely from region to region, being largely
determined by the socio-economic development and
the availability of primary health care and eye care
service. The corneal scarring from measles, vitamin A
deficiency disease, the use of harmful traditional eye
remedies and ophthalmianeonatorum are the major
causes in low-income societies. The retinopathy of
prematurity is an important emerging cause. Other
significant but less common causes are cataract,
congenital abnormalities, and hereditary retinal
dystrophies.10
Various studies have been done on childhood eye
problems in Pakistan. Afghani and colleagues3
screened one million children; with main focus on
prevalence of refractive error. Their study showed
about 4.24% of children having various refractive
errors required spectacle correction. Masood11 looked
at the various “institutions for the blind children” and
found chorioretinal hereditary ocular disease
involving 50.7% of children.
There is paucity of literature in finding the
prevalence of ocular disorders in children studying in
Pakistan Journal of Ophthalmology
 PATTERN OF OCULAR PROBLEMS IN SCHOOL GOING CHILDREN OF DISTRICT LASBELA, BALOCHISTAN
madaris and comparing the ocular morbidity with
children in government sponsored schools.
The present study was conducted in all schools,
managed both by the government and the religious
bodies to cover all the children of school going age
between 6-15 years in district of Balochistan (Lasbela).
A total of 27,924 students were registered in the area
schools. During screening, 2,487 students were found
absent with 25,437 students available for ocular
examination. It may be of some interest that 84.25% of
the students were registered in state run school.
Considering only the school going children, out of
25,437 children 5,808 students (22.23%) were found to
have eye problems. A considerable difference was
Pakistan Journal of Ophthalmology
noted in the disease pattern between madaris students
and state run schools. In former 34.3% students (1,375
out of 4,005) had eye problems whereas in later only
20.35% (4,433 out of 21,432) needed medical attention.
This difference was mainly due to conjunctivitis and
refractive error. In schools, 10% of the children
suffered from conjunctivitis as compared to 17.0% of
the students of madaris. The apparent cause was not
the difference between hygienic environments but the
fact that all the students in madaris were residents
causing easy spread of the disease. The second
important cause was refractive error with 2.14% of
school students and 7.00% students from madaris
having various refractive problems. Prevalence of
refractive errors in school going children varies from
0.5% in Nepal12 to 5.1% in India.13 The second National
Blindness and Impairment survey of 2002-314 had
shown refractive error as 2.7% of the blindness in all
ages.
The variation of various studies on childhood eye
problems can be due to racial factors; but lack of
standardization of the screening procedures cannot be
over looked. The high prevalence of refractive error in
children in madaris certainly needs some consi-
deration. A similar study conducted by Zylbermann in
Jewish religious students has also shown the increased
prevalence of myopia. Abdullah and Abdullah15
examined 3,153 students, age 5 – 15 years studying in
madaris of district Peshawar, to determine the
prevalence of blindness and low vision. Refractive
error was the main cause of low vision (VA between
6/18 and 3/60 in better eye) in this study. Out of 142
children (4.5%) with low vision, 130 (4.1%) children
had uncorrected refractive error and 10 (0.4%) had
causes such as: hereditary maculopathies, optic nerve
atrophy, amblyopia and cataract. Our study found
refractive error in 7% of children in madaris compared
to only 2.1% of students enrolled in schools.
Continuous accommodation has been proposed to
play some role in the axial development of the eye
resulting in myopia.16 The uncorrected refractive error
may have a dramatic impact on the learning capacity
of children and their education potential.17
Fortunately, refractive error is easily treatable, with
the provision of a pair of spectacles, which is
extremely cost-effective and provides immediate
solution to the problem. The provision of affordable
spectacles is another component of WHO’s vision 2020
program.18 A cross sectional study by Deshpande and
Malathi19 in 622 children of age 10 – 15 years, found
prevalence of ocular morbidity at 27.65%. Refractive
Vol. 28, No. 4, Oct – Dec, 2012 203
KHALIL A. LAKHO, et al
error was the leading cause of ocular disorder (10.12%)
followed by vitamin A deficiency (7%) and
conjunctivitis (2.57%). The higher prevalence of
conjunctivitis in our study at 11.10% can be due to
seasonal variation and the short duration of the
disease. In another study Alam and coworkers20
examined 1000 children from 20 schools in Karachi
and found 8.9% students with refractive error. This
figure is higher than our study where we found
overall 2.90% children with refractive error, 2.14% in
schools and 7% in madaris. The prevalence of
conjunctivitis was also found higher at 8% in a study
carried out among students in south western Nigeria.21
Our study showed that 5,808 (22.8%) of the school
going children had ocular problem. The important
causes of impaired vision and possible blindness
among them were refractive error (2.9%), VADD
(3.29%), cataract (0.17%), nystagmus (0.1%), ptosis
(0.1%), squint (0.46%), glaucoma (0.007%) and possibly
vernal conjunctivitis (1.9%) in advanced stage
involving cornea.
From the management point of view, the eye
problems can be grouped under three categories:
manageable at primary health care level, secondary
level and tertiary referral center level.
The ocular problems such as conjunctivitis,
blephritis, and VADD can be easily prevented by the
health education of the community and can be treated
by mid-level eye care providers. In this way, 69.5%
(4,038) of the eye problems according to this study can
be prevented or treated at primary level. Amongst
these diseases, VADD is a potentially blinding disease
and an important cause of nutritional blindness.
Conjunctivitis though a harmless disease, can result in
sight threatening corneal involvement. The refractive
error was responsible for 2.90% (no = 740) of the
ocular problem present in this study and can be
managed by a refractionist. As there is a lack of this
resource, the nearest place to refer the children would
be to Tahseel headquarter (THQ) hospital. The
training of this cadre can provide such service at the
primary level making it more accessible and
affordable. A well-trained refractionist can manage
amblyopia, adding another 21.07% (no = 1224) to the
cases to be managed at the primary level. According to
this study 90.57% of the ocular problems of school
going children can be managed at primary level
provided by well-trained mid – level eye care
personnel. The remaining 484 children (9.3%) having
cataract, nystagmus, ptosis, squint, glaucoma and
undiagnosed ocular problems needed referral to a
204 Vol. 28, No. 4, Oct – Dec, 2012
tertiary center for further management. Most of these
congenital diseases cannot be prevented, but if
diagnosed at the right time and treated, can save
vision. Though, we only screened school going
children between 6 – 15 years of age, there are surely
children under 6 years of age, having various ocular
problems. In this respect, government and various
non-governmental organizations (NGOs) have to
formulate a strategy to screen these children at pre-
school level. Also 2487 students were found missing /
absent from the schools, but even on repeated visits
these students could not be found attending schools,
making their enrollment in schools questionable.
CONCLUSION
Almost 23% of school going children in Labella district
needed treatment for their ocular problems (34.33%
children in madaris and 20.68% in schools). Though
90% were managed at the primary eye care level, 9.3%
children needed referral to the tertiary care hospital
with 3.87% of them having potentially blinding eye
disease. The screening of school going children is
important as early recognition and prompt treatment
would reduce the ocular morbidity in that particular
age group.
Author’s Affiliation
Dr. Khalil A. Lakho
Isra Postgraduate Institute of Ophthalmology
Karachi
Dr. M. Zahid Jadoon
Isra Postgraduate Institute of Ophthalmology
Karachi
Prof. P.S. Mahar
Isra Postgraduate Institute of Ophthalmology
Karachi
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